The Trouble With Sleeping Pills

Many kinds of sleep aids are described here, but this does not mean we are recommending them. Over-the-counter (OTC) sleeping pills and dietary supplements are of limited use and have side effects. Prescription pills are more likely to quell insomnia, but being more potent they have greater risks.

More drawbacks of sleep aids: If you use them every night, you may become dependent on them; you can also develop a tolerance and thus need to keep upping the dose. When you stop taking them, you may have “rebound insomnia.” They can worsen sleep apnea. And sleep aids can cause impairment the next day, especially if you’re older, increasing the risk of falls, fractures and other accidents— even if you don’t feel drowsy. Of course, poor sleep itself can impair coordination and cause accidents, too.

OTC sleep aids

Most people start with nonprescription sleep aids, such as Sominex or Unisom. These contain a “first generation” antihistamine (diphenhydramine or doxylamine), which causes drowsiness. Though relatively safe, they can impair driving performance the next day.

What’s more, antihistamines have “anticholinergic” effects (meaning they interfere with the neurotransmitter acetylcholine), which can cause or exacerbate memory problems, confusion and cognitive impairment in older people, and can also worsen difficulties with urination in older men who have an enlarged prostate.

Tolerance to the antihistamine’s sedative effect can develop fairly quickly, so don’t take OTC sleep aids for more than a few nights in a row.

Nighttime pain relievers (such as Tylenol PM and Advil PM) and cold remedies (such as Nyquil) also contain such antihistamines to promote drowsiness. If all you need is pain relief at night, you should just take the acetaminophen (Tylenol) or ibuprofen (Advil, Motrin). And if you simply need help sleeping, skip the pain reliever and just take the antihistamine (diphenhydramine).

Sleep Aids: Benzos and Beyond

Sleep Aids: Benzos and Beyond

Prescription sleeping pills fall into three general categories. The drugs differ primarily in how fast they kick in and how long the sedative effect lasts.

Prescription sleeping pill choices

There’s a wide variety of prescription sleeping pills. They are generally effective and safe when used as directed, with a lot of caveats (the package inserts are required reading). These drugs are categorized as “controlled substances” for good reason, since dependency, tolerance and abuse can occur.

They can also have some strange adverse effects. In particular, there have been reports about zolpidem (brand name Ambien), the most popular sleeping pill, causing people to drive, cook, walk and binge eat while sleeping or semi-asleep. The Food and Drug Administration (FDA) now requires makers of zolpidem and many other sleeping pills to warn about these unusual behaviors.

Earlier this year the FDA issued a new warning about sleeping pills and driving, especially for women taking zolpidem. Since it takes women longer to metabolize the active ingredient, their blood levels tend to remain elevated much longer. Thus, the FDA advised women to take only half the dose previously recommended, and it made drug companies change their labels accordingly. It also suggested that men start with lower doses.

In addition, a widely publicized study in BMJ Open linked prescription sleeping pills to a higher risk of death. In large part, this may be because the drugs increase the risk of falls and impaired driving—as well as worsening sleep apnea. Some earlier observational studies have had similar findings.

And then a study published this year in the British journal BMJ linked one class of sleeping pills, benzodiazepines, to an increased risk of dementia in people over 65.

These were observational studies and don’t prove that sleeping pills cause dementia or shorten your life. Still, this is one more reason to limit your use of the drugs.

Sleeping pill precautions

Take the lowest effective dose. Try halving the dose listed on the label.

Don’t drink alcohol if you plan to take a sleeping pill since that increases the risk of side effects.

Don’t take a sleeping pill if you are a pilot, firefighter, caretaker or health care provider on call.

Don’t drive a car or use machinery (such as power tools) if you feel groggy or hung over after taking a pill the night before. Even if you don’t feel groggy, consider not driving the next morning.

Bottom line: No matter what the ads say, there is no “best” pill. Your goal should be not to need sleeping pills. Your doctor should not simply renew your prescription, but should ask you about your progress and whether you’ve had side effects.